Evaluating skeletal muscle in chronic liver disease: remaining challenges

Skeletal muscle alterations are increasingly recognized as determinants of prognosis in chronic liver disease, and computed tomography (CT) has made their assessment widely accessible. However, interpretation of these measurements raises several challenges. First, myosteatosis is usually inferred from low CT muscle attenuation, which has not been validated against intramuscular fat content in cirrhosis. Second, muscle alterations may differ according to the aetiology of liver disease, and studies pooling aetiologies may obscure aetiology-specific patterns. Third, "sarcopenia" is frequently incorrectly used for low muscle mass alone, whereas incorporating muscle function, better predicts adverse outcomes in chronic liver disease. Addressing these issues is necessary before muscle quality can become a reliable clinical biomarker.